Exocrine drainage in vascularized pancreas transplantation in the new millennium

Abstract

The history of vascularized pancreas transplantation largely parallels developments in immunosuppression and technical refinements in transplant surgery. From the late-1980s to 1995, most pancreas transplants were whole organ pancreatic grafts with insulin delivery to the iliac vein and diversion of the pancreatic ductal secretions to the urinary bladder (systemic-bladder technique). The advent of bladder drainage revolutionized the safety and improved the success of pancreas transplantation. However, starting in 1995, a seismic change occurred from bladder to bowel exocrine drainage coincident with improvements in immunosuppression, preservation techniques, diagnostic monitoring, general medical care, and the success and frequency of enteric conversion. In the new millennium, pancreas transplants are performed predominantly as pancreatico-duodenal grafts with enteric diversion of the pancreatic ductal secretions coupled with iliac vein provision of insulin (systemic-enteric technique) although the systemic-bladder technique endures as a preferred alternative in selected cases. In the early 1990s, a novel technique of venous drainage into the superior mesenteric vein combined with bowel exocrine diversion (portal-enteric technique) was designed and subsequently refined over the next ≥ 20 years to re-create the natural physiology of the pancreas with first-pass hepatic processing of insulin. Enteric drainage usually refers to jejunal or ileal diversion of the exocrine secretions either with a primary enteric anastomosis or with an additional Roux limb. The portal-enteric technique has spawned a number of newer and revisited techniques of enteric exocrine drainage including duodenal or gastric diversion. Reports in the literature suggest no differences in pancreas transplant outcomes irrespective of type of either venous or exocrine diversion. The purpose of this review is to examine the literature on exocrine drainage in the new millennium (the purported "enteric drainage" era) with special attention to technical variations and nuances in vascularized pancreas transplantation that have been proposed and studied in this time period.

Keywords: Enteric conversion; Pancreas transplantation; Portal-enteric drainage; Simultaneous pancreas-kidney transplant; Solitary pancreas transplant; Systemic-bladder drainage; Systemic-enteric drainage.

Figure 1

Technique of systemic-bladder drainage with creation of an anastomosis between the allograft duodenal segment and vesical dome of the recipient bladder.

Figure 2

Technique of conversion from bladder to enteric exocrine drainage (enteric conversion) for persistent metabolic, urologic, or other problems.

Figure 3

Technique of systemic-enteric drainage with side-to-side anastomosis between allograft duodenum and recipient small bowel.

Figure 4

Technique of portal-enteric drainage with side-to-side anastomosis between allograft duodenum and small bowel; this technique is also amenable to using the native duodenum or stomach for exocrine diversion.